Enriched formula milks and academic performance in later childhood

Effect of nutritionally modified infant formula on academic performance: linkage of seven dormant randomised controlled trials to national education data
Added nutrients have no cognitive benefits and could cause harm – LINK

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Enriched formula milks and academic performance in later childhood. Editorial BMJ –  LINK

One goal of modifying infant formula is to make long term cognitive outcomes more like those seen in breastfed infants. This study looked at three types of modified infant formulas, which are widely available and have been proposed to promote cognitive development: formula enriched with nutrients, formula supplemented with long chain polyunsaturated fatty acids (LCPUFAs), and follow-on formula fortified with iron.

The researchers tracked 1763 participants in seven randomised controlled trials of novel infant formulas, started between 1993 and 2001, and linked 91% of them to centrally collected, objective, educational outcomes at ages 11 and 16 years.

Researchers noted that participants in five out of the seven supplemented arms fared slightly (but not significantly) worse than controls in national maths examinations at age 16 years. Scores for both maths and English were significantly lower at age 11 years, though not at 16 years, for participants given enriched formula milk in the two LCPUFA trials. This finding is consistent with a meta-analysis by the same research group suggesting that adding LCPUFA to formula milk is harmful to cognition.4 Despite their findings, formula milks are often supplemented with the LCPUFA docosahexaenoic acid, and in the European Union this is mandatory.5

Researchers found no differences in cognition associated with iron supplementation, but they noted that a previous study found reduced cognition at age 16 years among children who had received formula milk supplemented with iron in infancy.6 Breast milk contains little iron, and the likely evolutionary reason for this is that iron in the gut facilitates the growth of pathogenic bacteria.7 Manufacturers of formula milk advertise the addition of iron to follow-on milks, which could be interpreted as an advantage of formula milk over breast milk. Given the lack of benefit associated with supplementary iron8 and its possible adverse effect on growth9 and now cognition,6 it is time to consider whether current regulations governing the composition of formula milks need review worldwide.10

What is already known on this topic

  • Infant formula is consumed globally by more than 60% of infants aged <6 months

  • Unlike other early interventions to support cognitive development, infant formula modifications are highly scalable; evidence that modifications of infant formula result in long term cognitive advantages is important for public health

  • The benefits for long term cognitive ability that have been claimed for nutrient enriched formula, long chain polyunsaturated fatty acid supplemented formula, and high iron follow-on formula are uncertain because of the high attrition rate in randomised controlled trials

What this study adds

  • Attrition was minimised by linking seven dormant infant formula trials to administrative school data with section 251 (NHS Act 2006) support, instead of consent

  • Primary outcome data (results of GCSE mathematics examinations at age 16) were available for 86% of participants in the eligible age range

  • No cognitive benefit, as measured by academic performance, was found for any of the modified formulas (nutrient enriched, long chain polyunsaturated fatty acid supplemented, iron fortified follow-on formula, sn-2 palmitate supplemented, and nucleotide supplemented), consistent with the original trials and the external literature

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